OASIS Recertification Assessment (60-Day)

Inspection template for the every-60-day OASIS recertification assessment used to confirm continued home health eligibility, document current status, and update the plan of care for the next episode.

Assessment Timing and Episode Eligibility

• Recertification assessment completed on or before the 60-day recertification date
  Confirm the assessment date aligns with the current episode recertification schedule and is documented within the required timeframe.
• Current episode and recertification dates are documented accurately
  Verify the episode start/end dates, recertification date, and assessment date are consistent across the record.
• Continued eligibility for home health services is supported by the record
  Confirm documentation supports ongoing skilled need, homebound status when applicable, and continued need for intermittent skilled services.
• Any gap, delay, or late recertification is explained
  Document whether the recertification was completed late and whether the reason is clearly explained in the record.

Patient Status and Functional Change

• Current clinical status is documented and reflects the patient’s condition
  Verify the assessment captures current symptoms, diagnoses, treatment response, and relevant clinical changes since the prior episode.
• Functional status is updated and consistent with observed performance
  Confirm mobility, transfers, ADLs, cognition, and other functional indicators are updated based on current findings.
• Relevant changes from prior OASIS assessment are identified
  Document meaningful improvement, decline, or stability that affects care planning or eligibility.
• Patient goals and response to treatment are reviewed
  Verify the record reflects progress toward goals, barriers to progress, and current response to interventions.

Plan of Care Update

• Plan of care is updated to reflect current patient needs
  Verify the care plan includes current skilled interventions, frequency, and discipline-specific services.
• Goals are current, measurable, and appropriate for the next episode
  Confirm goals are specific, time-bound, and aligned with the patient’s current status and expected outcomes.
• Medication, treatment, and equipment needs are reviewed and updated
  Verify any changes to medications, wound care, durable medical equipment, supplies, or therapy needs are reflected in the plan.
• Discharge planning or ongoing service needs are addressed
  Confirm the plan includes anticipated discharge criteria or continued service rationale as appropriate.

Physician Communication and Orders

• Physician or allowed practitioner is notified of recertification findings
  Confirm communication of the recertification assessment results and any significant changes is documented.
• Updated orders support the revised plan of care
  Verify orders are present, current, and consistent with the updated services and frequency.
• Any verbal orders or order changes are documented per policy
  Confirm order changes, if any, include date, time, authorizing clinician, and follow-up documentation.
• Signature or authentication requirements are met
  Verify the assessment and related documentation are signed or authenticated according to agency policy and applicable requirements.

Documentation Quality and Compliance

• Assessment responses are complete and internally consistent
  Confirm there are no missing fields, contradictory entries, or unexplained discrepancies across the recertification record.
• Narrative supports the coded assessment findings
  Verify the narrative or supplemental notes support the documented assessment responses and plan-of-care decisions.
• Required supporting documentation is present
  Confirm supporting notes, visit documentation, orders, and related evidence are available in the chart.
• Corrective actions are documented for any deficiencies
  If deficiencies or non-conformances are identified, verify corrective actions, responsible party, and due date are recorded.

Inspector Review and Sign-Off

• Overall inspection result
  Select the final outcome of the recertification audit.
• Inspector comments
  Summarize key findings, deficiencies, and any follow-up actions required.
• Inspector signature
  Signature confirming the review was completed.